i) Weight

ii) Blood Pressure

iii) Fundal height

iv) Fetal heart rate

v) Urine for protein and glucose

Review any other problems/concerns the patient may have related to pregnancy or general well being, including nutrition.

6-12 Weeks

i) Confirmation of the uterine size and growth by pelvic examination.

ii) Doppler scan for fetal heart rate and tone, which is usually audible by doppler at 10-12 weeks of gestation.

iii) Transvaginal Chorionic Villus Sampling. The ideal time to do a transvaginal chorionic villus sampling (Only if indicated) is 10- 12 weeks.

Transvaginal chorionic villus sampling is used for screening of trisomy 18, 21 and cardiac defects.

The parameters used for screening include nuchal translucency via sonography, hcg and PAPP-A.

12- 18 Weeks

i) Genetic counseling: of women aged 35 years or older at delivery or for those with a family history of congenital anomalies.

Women who have had a previous child with a chromosomal abnormality , metabolic disease or neural tube defect should also be counseled.

ii) Amniocentesis: Can be performed as indicated (Usually after counseling for genetic abnormalities-see above) and requested by the patient.

12- 24 Weeks

i) Fetal ultrasound scan: The best time for a dating fetal ultrasound scan (To confirm the correct age of the fetus) is 18-20 weeksof gestation.

Ultrasound scan done around this time is also useful to evaluate fetal anatomy.

16-20 Weeks

i) Maternal serum alpha-fetoprotein test: This should be offered to all women to screen for neural tube defects. In some states of the USA this test is compulsory.

The serum alpha-fetoprotein measurement can be combined with the measurement of hcg and estriol (Called the triple screening test for fetal Down’s syndrome) or inhibin A (Quad screen test for Down’s) for the detection of fetal Down’s syndrome.

20-24 Weeks

i) Cervical length measurement by ultrasound: This is very important in women with a previous history of preterm labour .It should be measured from 18 weeks in women with a history of preterm labour (>2.5 cm is normal).

24 Weeks to Delivery

i) Perform ultrasound scan as indicated for fetal size and growth-usually evaluated when fundal height is 3cm less than or greater than expected for gestational age.

In diagnosed cases of multiple pregnancy ultrasound scanning should be performed every 4 weeks.

26- 28 Weeks:

i) Screening for gestational diabetes by a 50g glucose load (Glucola) followed by a 1-hour post-Glucola blood glucose determination.

If values of the 1-hour test ate abnormal, it should be followed up by 3-hour glucose tolerance test.

28 Weeks:

Repeat antibody testing for Rh-negative patients if the initial antibody screen is negative.

Please note that the result is not necessary before Rh (D) immune globulin is administered.

28-32 Weeks:

Repeat the complete blood count to evaluate for anemia of pregnancy.

28 Weeks to Delivery:

Determination of the fetal position and presentation. The patient should be questioned at each visit for the symptoms and signs of preterm labour or rupture of membranes.

Maternal perception of fetal movements should be assessed at each visit.

Other investigations such as CTG can be performed if indicated.

36 Weeks to Delivery:

i) Repeat syphilis test, HIV test, cervical cultures for N gonorrhoea and Chlamydia trachomatis in at-risk patients.

ii) Discuss with the patient the signs and symptoms of the onset of labour, pain management during labour and the management of labour and delivery.

iii) Fetal lung maturity tests for all elective cesarean sections.

iv) The CDC (Atlanta) has recommended universal prenatal culture based screening for group B streptococcal colonization in pregnancy.

a single standard culture of the vagina and anorectum should be collected at 35 to 37 weeks of gestation.

Prophylaxis should be given only if the cultures are positive.

In patients who have not done the screening, the risk factors for ascending infection are intrapartum temperatures greater than 38 degrees celsius or membrane rupture greater than 18 hours.

Recommended prophylaxis :

penicillin G, 5 million units intravenously as a loading dose followed by 2.5 million units intravenously every 4 hours until delivery.

Alternatively 2g of Cefazolin intravenously followed by 1g intravenously every 8 hours until delivery.

41 Weeks and Beyond:

Examination of the cervix to determine the probability of successful induction of labour. If the cervix is favourable (> or =50% effaced, cervix> or = 2cm,vertex at -1 station, soft cervix and midposition) ,induction of labour can be undertaken.

If unfavourable antepartum fetal testing is begun while preparing for a cesarean section delivery